Medicine's blindspot: When stress and emotions affect you physically

Let me give it to you straight: your brain can screw you up good. Mentally AND physically.?

The fact that chronic diseases can lead to mental health disorders such as depression and anxiety is widely accepted among the medical community. Around 40% of patients diagnosed with cancer will suffer from a severe episode of depression (Boyd et. al. 2000).?

Everyone accepts that we may experience physical reactions to stressful events like blushing, an upset stomach or sweating. But the fact that mental health disorders can also create acute and/or chronic physical symptoms is still overlooked by most doctors. This is a major blind spot that leads to poor medical outcomes for the patient.?

Stress and emotions can lead the brain to change its wiring (neural pathways) and create chronic and often severe physical symptoms.

Not convinced by how powerful the brain is??

In 1995, the British Medical Journal reported on a 29-year-old construction worker who'd suffered an accident: after jumping onto a plank, a 7-inch nail pierced his boot clear through to the other side (Fisher et al, 1995). In terrible pain, he was carted off to the ER and sedated with opioids. When the doctors removed his boot, they discovered the nail had passed between his toes without penetrating his skin! Yet this person was in terrible pain.

Here comes the WTF moment

Let’s look at back pain. A 2019 study from the CDC states that about 40% of adults suffer from back pain. Hundreds of millions are spent each year on imaging, drugs, and procedures.

1. In 2005, the NEJM published a piece by Eugene J. Carragee (a Stanford University Orthopedist)” He wrote, “neither baseline MRIs nor follow-up MRIs are useful predictors of lower back-pain (...) ill-considered attempts to make a diagnosis on the basis of imaging studies may reinforce the suspicion of serious disease, magnify the importance of nonspecific findings and label patients with spurious diagnoses”.
2. Back and neck pain peak between 45 and 64 years old and decline after 65 (Strine, 2007).
3. In a large population of healthy individuals (=no pain reported), 50% of healthy 30 year-olds have degenerative disc disease and 40% have bulging discs. 80% of healthy 50 year-olds have generative disc disease and 60% bulging discs, and the number goes up from there (now read point 2 again).
4. A few months ago, an MRI of my spine came out bad, and the doctors actually asked me how I could not be in severe pain with their findings. I feel 0 pain in my back.??

You want to (not) laugh??

A review of back pain treatments found that neither surgery, injections or narcotic pain medications have been shown to be more effective than placebo treatment or conservative treatments (Deyo et. al. 2009, Deyo, 2015).

The issue is most doctors don’t go past the way they were trained, which is to think in silos.

“If the back hurts, there must be something wrong with it”, and approach the problem on a tissue or molecular level only, leading to obvious blind spots. This results in either getting frowned at by your doc and getting a “there’s nothing wrong with you, go home”, or unnecessary testing, and/or a misdiagnosis leading to surgery, medication, etc. Sometimes your doc might not be able to tell you what you have and say “it must be stress”. As frustrating as it sounds, they may actually not be wrong!?

According to the Mayo Clinic, symptoms induced by stress can include neurological aspects: weakness or paralysis, abnormal movements, such as tremors or difficulty walking, loss of balance, difficulty swallowing or feeling "a lump in the throat", vision problems, such as double vision or blindness, cognitive difficulties involving memory and concentration. As Dr. Howard Shubiner puts it (the director of the Mind-Body Medicine Center at Providence Hospital in Southfield, Michigan and an internal medicine specialist) “your brain can generate virtually any symptom”.?

In the case of a close friend, 7 docs in 4 different specialties were not able to pinpoint the source of his symptoms. The multiple tests he had gone through over five months included bloodwork, electromyogram, nerve conduction study, CT scan, MRI, and panendoscopy. They all came back negative. Guess what his docs told him? There’s nothing wrong with you. Yet his worrisome neurological symptoms and pain were very real.?

According to Dr. Shubiner, having the false belief that one might have a serious or intractable condition causes activation of more stress and emotional reactions which can exacerbate the problem.???

How does this work then?

First, it’s important to understand the fight or flight mechanism. It’s designed to keep us alive. When you believe you’re in danger, your body follows a predetermined automatic physiological response that prepares the body to fight or flee. Your blood flow shifts from your frontal lobe (the rationale part of your brain that thinks) to your limbic system (the unconscious part of your brain that includes your autonomic nervous system).

Your autonomic nervous system then stimulates the adrenal glands, triggering the release of catecholamines (including adrenaline and noradrenaline). This results in dilation of blood vessels and pupils, increased breathing rate and heart rate to send more oxygen to your muscles.

When your context is a repeated or permanent stress stimulus, your brain can also trigger the fight or flight mechanism since stress induces a protective reaction. Over time the machine can break due to repeated use, leading your brain to adapt and reprogram itself differently and stay in permanent fight or flight mode. This can lead to physiological changes in your body (blood flow, nerve wiring and brain wiring patterns).?

The link between emotions and pain

Chronic stress is known to increase sensitivity to pain in the brain, spinal cord, and nerves (Lieberman et. al., 2004). As Rachel Zofness, a pain psychologist, puts it: we know the level of perceived pain is your brain’s best guess as to whether your body requires protection, and how much (Moseley & Butler, 2015). Your perceived level of danger will trigger an equivalent pain response. Hence why in the context of chronic stress and over-sensitive pain receptors, you may experience constant and sometimes severe pain.??

Good news: perception works both ways. Cognitive, emotional, and contextual factors like excitement, distraction, and pleasure can tune up or down our perception of danger and hence regulate the level of pain we experience. I've played rugby at an elite level for years. A game is 80 minutes of impacts ranging from 10G to 40G (for reference, a car crash at 65km/hr or 40 miles/hr is around 30G). Only after the games did I realize the damage done to my body: huge bruises, broken foot, etc. Most of the time I’d have minimal, if not zero, pain during the game. The focus of your attention and context indeed matters.

It’s a widespread phenomenon

The American Psychology Association published a study in 2007: 77% of people living with stress report experiencing physical symptoms. In 2020, the American Psychology Association stated in the Stress in America 2020 report that “we are facing a national mental health crisis that could yield serious health and social consequences for years to come (...) For nearly 8 in 10 adults the pandemic is a significant source of stress in their life”. Imagine how many of them will experience physical manifestations from their stress. How many will have unnecessary tests and misdiagnoses?

5 takeaways?

1. Medical training needs to focus more on this Mind-Body connection and doctors need to be more empowered by health systems, whether public or private, to approach the mind and the body at the same time.?
2. The links between stress and its physical consequences is still not quite understood. A promising relatively new field in medicine is psychoneuroimmunology. It studies the link between your central nervous system and your immune system, and we already know emotional stress can have a very real effect on your immune system. This could lead to a better understanding of life-threatening issues, like cancer and coronary artery disease for instance. It’s going to take years before this new knowledge trickles down in our healthcare systems. In the meantime:
3. Understanding the relationship between stress and physical symptoms is paramount. A good place to start to understand how the mind controls health are two books: When the Body Says No by Gabor Maté, M.D., and Unlearn Your Pain by Howard Shubiner, M.D.
4. Working on a more appeased mind is never a wrong decision regardless of your pain level, and there is increasing medical evidence on the benefits. Mindfulness, relaxation, etc.: find what works for you.
5. You have much more control over your pain than you realize. Changing thoughts, what you think, how you feel, and what you believe about your body and your health can change the pain you feel. Credible evidence that your body is in danger can amplify pain, while credible evidence of safety can reduce pain (Butler & Moseley, 2013). I’ve experienced it firsthand.?

Running a team of 800+ health care providers both in physical and mental health, I’m convinced that mental health and physical health are indissociable both on the preventative and curative aspects. We have one body in which both sit and constantly interact with each other. I’m certain that continuing to look at them independently will never yield the best health outcomes.